Gastric emptying in the critically ill patient.

OBJECTIVE To review the pathophysiology of gastroparesis and present a practical approach to the management of this disorder in the critically ill patient. DATA SOURCES Articles and published abstracts on the mechanisms and management gastroparesis relevant to the critically ill patient. SUMMARY OF REVIEW The importance of early enteral nutrition in the critically ill patient has been recognised for many years. However, while nasogastric tubes are easy to insert, gastric dysmotility is common, and often hinders the introduction of effective enteral nutrition. Small bowel motility problems are uncommon in the intensive care patient, and direct instillation of nutrients into the jejunum will allow enteral nutrition to begin without delay. However compared with gastric tubes, jejunal tubes are often difficult to insert, often requiring endoscopic or surgical techniques. The cause of gastric dysmotility is multifactorial. Treatment of underlying sepsis, pain, hypotension, dehydration and hyperglycaemia should occur, and opiates and dopamine should be avoided before commencing prokinetic agents. The patient's head should remain elevated, and oral or nasogastric cisapride (10 mg 6-hourly) administered. If this is not effective then erythromycin (e.g. 250 mg i.v. 8-hourly) may be included. CONCLUSIONS Gastric dysmotility is common in the critically ill patient. However, treatment of the underlying conditions leading to gastroparesis and the introduction of prokinetic agents will allow the majority of patients to be successfully fed enterally.